Patients age 80 and older did not share the same outcome benefits as younger patients with endovascular therapy (EVT) for large vessel occlusion (LVO) ischemic stroke, an observational prospective cohort study found.
For the primary outcome — functional status measured with the modified Rankin score (mRS
There were no differences in the odds of successful reperfusion or symptomatic intracerebral hemorrhage among age quartiles, patients 80 and older had worse 90 day outcomes: their risk of death was 3 times higher (50.9% versus 21.8%, acOR 3.12; 95% CI 2.33–4.19) and odds of good functional outcome were 59% lower (20.3% versus 45.6%, acOR 0.41; 95% CI 0.30–0.56).
“Our results show that in patients with acute ischemic stroke (AIS) older age is associated with an increased absolute risk of poor clinical outcome after EVT in routine clinical practice compared to younger patients,” Coutinho and colleagues wrote in Neurology.
“Despite an overall worse outcome, we found a stronger association between successful reperfusion and clinical outcome in older adults than younger patients,” they added.
This represents a relative increase in outcome benefit for older patients, the authors noted, one they suggest is likely due to a difference in the absolute chance of good functional outcome between old and young patients. “Because the overall absolute chance of good outcome is lower for older adults, the relative benefit is higher in these patients,” they explained.
“It is important to note that, despite the overall decreased absolute chance of good outcome in older adults, the risk of severe disability (mRS score 4–5) was not higher in these patients, nor did major bleeding occur more often,” the authors concluded. “These data, together with the observed increased relative benefit of successful reperfusion in older adults and the fact that almost 20% of older patients are independent at follow-up, should be taken into consideration in the selection of older adults for treatment with EVT.”
In an accompanying editorial, Luciano Sposato, MD, of Western University in London, Canada, and Svetlana Lorenzano, MD, PhD, MSc, of Sapienza University in Rome, Italy, wrote that the study “suggests that, in the setting of real world practice, mechanical thrombectomy in the elderly population is associated with substantially worse outcomes than in younger patients despite similar reperfusion and symptomatic intracerebral hemorrhage rates.”
“Higher numbers of deaths occurring early after stroke accounted for the greater mortality of older patients, suggesting that it was driven upfront by worse periprocedural outcomes or stroke-related factors rather than longer-term complications,” the editorialists added. “This remains on hypothetical grounds because the authors did not report causes of death.”
Demographic changes suggest that a substantial number of EVT treatment decisions will involve older adults, but outcome data for older patients has been mixed.
The HERMES analysis of data from five trials found better 90-day mRS outcomes in those 80 or older for mechanical thrombectomy versus a standard care control group. A meta-analysis of observational studies found that while outcomes in those older than 80 were inferior to those of younger patients, at least one in four patients regained independent function at 3 months, and concluded that age should not be a discriminator when deciding to offer EVT with AIS.
In their study, Coutinho and colleagues analyzed data from the ongoing MR CLEAN trial registry, a prospective study of endovascular therapy in the Netherlands. They included data from 1,526 elderly patients (median age 71; range 18 to 99 years) with AIS and anterior LVO between March 2014 and June 2016. EVT treatment was at the discretion of the treating physician, and events were centrally adjudicated. Follow-up 90 day mRS outcome data was compared with initial mRS scores, and the oldest quartile (80 or older; n=380, about 25%) was compared to the three younger quartiles.
Participants in the oldest quartile were more likely female, more likely to be on antihypertensive and antithrombotic medication at the time of stroke, had greater risk factors, more comorbid conditions, more severe strokes (median NIHSS 17 versus 15, P=0.009), and worse collateral circulation. Longer time to groin puncture and higher rate of failure to reach the target occlusion were also seen in the oldest group.
Limitations inherent to observational studies include potential residual confounding and indication bias. Also, stroke etiology, lesion volume, and the degree of perfusion mismatch were not reported.
“The rapidly growing elderly population with one of the highest risks of embolic strokes with LVO underscores the need for randomized clinical trials specifically evaluating the efficacy and safety of mechanical thrombectomy in this age segment,” the editorialists observed.
Risk of poor 90-day modified Rankin scale outcome following endovascular therapy for anterior acute ischemic stroke was higher in patients age 80 or older than in younger patients.
Despite this, about one in five patients in the older group were functionally independent at 90 days.
Paul Smyth, MD, Contributing Writer, BreakingMED™
The MR CLEAN Registry was partly funded by the TWIN Foundation, Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC.
Coutinho received unrelated research support from the Dutch Heart Foundation, Bayer, Boehringer, and Medtronic.
Sposato received speaker honoraria from Boehringer Ingelheim, Pfizer, Bayer, GORE, and β Innovation; and has received research funding from the Kathleen & Dr. Henry Barnett Research Chair in Stroke Research, Edward and Alma Saraydar Neurosciences Fund, the Lawson Health Research Institute, the Opportunities Fund of the Academic Health Sciences Center Alternative Funding Plan of the Academic Medical Organization of Southwestern Ontario, Boehringer Ingelheim, and Bayer.
Lorenzano served as an expert consultant for Boehringer Ingelheim; and received travel grants from Boehringer Ingelheim, Bayer, Quintiles IMS, and Daichii Sankyo.
Cat ID: 38
Topic ID: 82,38,730,8,38,192,925